Background and Summary
There are 561 federally-recognized American Indian tribes in the United States. These tribes have a government-to-government relationship with the United States. This unique relationship has been recognized in numerous Supreme Court decisions, treaties, legislation, and executive orders. The United States’s provision of health services to American Indians grew out of this government-to-government relationship. The principal legislation authorizing federal funds for health services to recognized Indian tribes is the Snyder Act of 1921 (25 U.S.C.13).
The American Indian population generally has a significantly higher incidence of illness and premature mortality than the United States population as a whole. The Indian Health Care Improvement Act (IHCIA) was originally enacted in 1976 to establish a comprehensive framework for the delivery of health care services for American Indian people. The original legislation acknowledged that the United States has a legal obligation to provide health care services to eligible American Indians. The goal of IHCIA is to provide the quantity and quality of health services necessary to elevate the health status of American Indians to the highest possible level, and to encourage the maximum participation of American Indian tribes in the planning and management of those services. The last comprehensive reauthorization of IHCIA took place in 1992, and authorized funding through Fiscal Year 2000. Congress enacted a one-year extension of IHCIA’s authority through Fiscal Year 2001, and since then, has merely continued to fund the programs under IHCIA via the annual appropriations process based on the general permanent authority under the Snyder Act.
The IHS is the principal federal health care provider for Indian people, with responsibility for the delivery of health services to an estimated 1.9 million American Indians. In recent years, appropriations for IHS have exceeded $3 billion annually. Under the Indian Self-Determination and Education Assistance Act of 1976 (25 U.S.C.450 et seq), tribes were given the option of either assuming from the IHS the administration and operation of health services and programs in their communities, or remaining within the IHS-administered direct health system. Today, nearly half of the IHS budget (more than $1.6 billion) is administered through tribal contracts under the Indian Self Determination and Assistance Act.
The Indian health delivery system is currently comprised of three components: the IHS, tribally-operated facilities and programs, and urban Indian organizations, which are non-profit programs funded through grants and contracts from the IHS. The IHS, tribal, and urban Indian health programs provide an array of basic medial, dental and vision services, including inpatient care and routine and emergency ambulatory care. These programs also provide medical support services, including laboratory, pharmacy, nutrition, diagnostic imaging, medical records and physical therapy, as well as other preventive, clinical and environmental health services.
The Indian health care facilities system is comprised of 163 local service units, which include 48 hospitals, 603 ambulatory care centers, and 34 urban Indian health centers. In general, persons eligible for IHS services reside in IHS service areas and belong to federally-recognized tribes. When health care services are not available at their facilities, IHS tribal and urban programs purchase medical care from the private sector through the Contract Health Services Program.
In addition to care provided by IHS, Indian people are also eligible for Medicare, Medicaid and the State Children’s Health Insurance Program (CHIP) on the same terms as other Americans. The original IHCIA legislation specifically authorized IHS and tribal health programs to recover reimbursements from Medicare, Medicaid, and CHIP. American Indians may also receive health coverage through employer-sponsored or other private coverage.
The effort to reauthorize IHCIA began in 1998, and reauthorization bills have been reintroduced since the 106th Congress to provide updates and improvements to current law. S.1200, the Indian Health Care Improvement Act Amendments of 2007, would reauthorize IHCIA for 10 years and provide more and better health care services to American Indians by:
- Establishing objectives for minimizing the health disparities that exist between Indians and the rest of the U.S. population;
- Enhancing the ability of IHS and tribal health programs to attract and retain qualified Indian health care professionals;
- Developing new mechanisms for reducing the backlog in health facility needs;
- Establishing a continuum of care through integrated behavioral health programs to address the substance abuse problems, and the social service and mental health needs of Indian people;
- Facilitating improved decision-making regarding program operations and priorities at the local tribal level in order to improve services to tribal populations;
- Enabling Indian people to use modern methods of health care delivery not currently available to them;
- Improving the efficiency of IHS; and
- Facilitating participation in Medicare, Medicaid, and CHIP, by eligible Indians and Indian health programs.
The Congressional Budget Office has estimated the cost of S.1200 over the 2008-2017 period to be $118 million in direct spending, and $35 billion in discretionary spending.
TITLE I – AMENDMENTS TO INDIAN LAWS
Title I of S.1200 would renew and improve IHCIA by accomplishing the following priorities:
Supporting the recruitment and retention of health professionals for Indian health programs. Difficulties in recruiting and retaining qualified health professionals have long been recognized as a significant factor impairing Indians’ access to health care services. S.1200 would address the health professional shortage in Indian communities by:
· Increasing recruitment and retention of health professionals for IHS, tribal, and urban Indian programs;
· Expanding college and graduate grant and loan repayment programs for students entering the health professions; and
· Expanding professional work and continuing education programs for individuals working for tribal and urban Indian health providers and federal health agencies.
Strengthening and expanding health services to American Indians. S.1200 would update IHCIA to reflect current Indian health needs, as well as current methods of health care delivery enjoyed by most other Americans. S.1200 would improve services by:
· Continuing authorization of the Indian Health Care Improvement Fund, to overcome health funding disparities and health status deficiencies in Indian communities;
· Requiring the establishment of an epidemiology center in each service area;
· Strengthening existing programs for the prevention, treatment, and control of diabetes, communicable, and infectious diseases;
· Expanding health promotion or disease prevention programs offered by schools, tribal, and urban Indian health organizations;
· Expanding mammography and other cancer screening services, consistent with national standards;
· Authorizing funding for hospice, assisted living, long-term care, and home- and community-based care, services that are not currently available to most Indian communities;
· Addressing Indians’ lack of access to health care services, often due to facilities’ limited hours of operation, by establishing grants for demonstration projects, including a convenient care services” program to expand the availability of health care; and
· Establishing an office of Indian Men’s Health to coordinate services to and promote the health status of Indian men.
Facilitating the construction, maintenance and improvement of facilities. S.1200 would update existing authorities for the construction of health facilities and sanitation facilities in Indian communities by:
- Directing the Secretary of Health and Human Services (HHS) to maintain a health care facility priority system for construction of various types of health care facilities in Indian communities; the system would be developed through consultation with impacted tribes;
- Requiring annual reports to Congress on the Indian health care facilities priority system, multiple lists of health care and sanitation priority facilities, and the methodology for establishing priority lists of facilities;
- Authorizing studies of guaranteed loan and loan repayment programs for Indian health facilities and facilities’ construction and renovation needs; and
- Providing flexibility for renovating, modernizing and expanding facilities, including the ability to leverage funds from multiple sources to construct, renovate or expand facilities, and to lease permanent structures without the need for Congressional action.
Increasing access to health services by facilitating third-party reimbursement. S.1200 would help remove existing barriers to obtaining third-party reimbursement for services by:
- Updating existing authorities to collect Medicare, Medicaid, and CHIP reimbursement for service delivered in IHS and tribal facilities;
- Allowing tribes to purchase health insurance for Indians or establish a tribal self-insurance plan with their tribal health funds;
- Codifying policies providing that entities operated by IHS, tribes, tribal organizations or urban Indian organizations shall be the payor of last resort when providing services to Medicare, Medicaid, and CHIP recipients.
- Improving grant opportunities to facilitate Medicare, Medicaid, and CHIP enrollment and outreach activities; and
- Allowing the HHS Secretary to enter agreements for the sharing of medical facilities and services with the Department of Veterans Affairs (VA) and the Department of Defense (DoD); if health care services are provided by the IHS or Indian tribe or tribal organization to Indians eligible for services from either the VA or the DoD, then the appropriate department would be required to reimburse the IHS, tribe or tribal organization.
Strengthening urban Indian programs. S.1200 would strengthen urban Indian health programs, which provide needed services to urban Indians who might not be able to obtain care elsewhere, by:
- Expanding the authority for urban Indian health organizations to lease, purchase, renovate, construct or expand facilities;
- Authorizing urban Indian youth treatment centers and grants for diabetes prevention, treatment and control;
- Requiring the HHS Secretary to establish certain new programs for urban Indian organizations consistent with those authorized for tribes and tribal organizations, such as behavioral health training, school health education, prevention of communicable disease, behavioral health prevention and treatment services, and youth multi-drug abuse;
- Authorizing grants to urban Indian organizations to employ Indians trained as health service providers through the Community Health Representatives Program; and
- Requiring the HHS Secretary to ensure that the IHS confers with urban Indian organizations.
Improving the organization and efficiency of the IHS. S.1200 would provide for direct lines of communication between the Director of the IHS and the HHS Secretary. The legislation would also establish and automated information management systems for the IHS.
Focusing on behavioral health. S.1200 would provide a strong focus on behavioral health, taking a comprehensive and integrative approach by:
· Consolidating existing authorities to provide for a comprehensive approach to behavioral health assessment, treatment and prevention;
· Authorizing federal agencies, tribal health, and urban Indian organizations to develop behavioral health programs that promote a continuum of care;
· Authorizing Indian youth behavioral health programs, including a tele-mental health demonstration program to address youth suicide;
· Making permanent existing programs addressing child sexual abuse prevention and treatment and fetal alcohol disorders;
· Supporting research, education, training and outreach on behavioral health issues; and
· Requiring cooperation between the Secretaries of the Interior and HHS in the delivery of behavioral health programs.
Implementing other miscellaneous improvements to IHCIA. In addition to the provisions described above, S.1200 would implement the following additional changes to IHCIA:
- Requiring negotiated rulemaking to implement particular sections of IHCIA;
- Mandating additional requirements for annual reports to Congress by the IHS;
- Establishing a National Bipartisan Commission on Indian Health Care to study health care delivery to Indians; and
- Establishing the Native American Health and Wellness Foundation, a federally-chartered, non-profit corporation to support Indian health.
TITLE II – IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER SOCIAL SECURITY ACT HEALTH CARE PROGRAMS
Title II of S.1200 would amend the Social Security Act to provide greater opportunities for American Indians to participate in Medicare, Medicaid, and CHIP by accomplishing the following priorities:
Facilitating federal payments to Indian health programs. Under current law, only
some Indian health programs may be reimbursed by Medicaid, Medicare, and CHIP
when they provide services to covered individuals. S.1200 would expand reimbursement to the full range of Indian health programs, including IHS facilities,
Indian tribes, tribal organizations, and urban Indian organizations.
Improving Medicaid and CHIP access. S.1200 would improve access to Medicaid and CHIP programs for Indians residing on or near reservations by directing the HHS Secretary to encourage states to achieve this goal using strategies like allowing program enrollment on or near the reservation, providing program outreach and education for Indian communities, and providing translation services.
Increasing outreach and enrollment of Indians in CHIP and Medicaid. S.1200 would allow states to exceed the current cap on total CHIP outreach spending to enroll Indian children and provide outreach for families likely to be eligible.
Eliminating cost-sharing, premiums and similar charges for Medicaid and CHIP. S.1200 would amend Medicaid and CHIP to exempt Indians from enrollment fees, premiums, deductions, co-payments, cost sharing, or similar charges for those who receive services from IHS, an Indian Tribe, Tribal Organization, or Urban Indian Organization.
Authorizing Payment for Services under Federal Health Programs. Some Indian health care providers are not currently licensed under state and local laws. Under S.1200, all health care providers operated by the IHS, an Indian tribe, tribal organization, or urban Indian organization would be exempt from state or local licensure requirements for purposes of their qualifying for reimbursement under federal health care programs such as Medicare, Medicaid and CHIP, if it is determined that they meet all applicable standards for such licensure. Any individual or entity that has been excluded from participation in any federal health care program, or whose state license has been suspended, would be prohibited from receiving reimbursement under any federal health care program.
Instituting consultation with tribes on federal health programs. S.1200 would amend the Social Security Act to establish a Tribal Technical Advisory Group (T-TAG) to help the HHS Secretary identify and address issues affecting Indians in federal health care programs. The legislation would also require states to seek advice regularly from designees of Indian Health Programs.
Establishing waiver authority for affected Indian health programs. S.1200 would allow the Secretary to grant an exception to federal regulations that may cause particular hardship to a specific Indian Health Program. The legislation also creates more flexibility in the way Indian Health Care Programs can pay outside providers for
Modifying Medicaid managed care entity rules. S.1200 would amend Medicaid’s
managed care rules to specify actions that states and managed care plans must take to
guarantee appropriate payment for Indian health care provider services to Indians in
Medicaid and CHIP.
Creating an annual report on Indians covered by federal health programs. S.1200 would require the HHS Secretary to submit a report to Congress regarding the enrollment and health status of Indians receiving items or services through health benefit programs funded under the Social Security Act.
On May 10, 2007, the Senate Committee on Indian Affairs approved by voice vote S.1200, the Indian Health Care Improvement Act Amendments of 2007, a bill that amends IHCIA. On September 12, 2007, the Senate Finance Committee approved by voice vote S.2532, the Medicare, Medicaid, and CHIP Indian Health Care Improvement Act of 2007, a bill that amends the Social Security Act.
When the Senate proceeds to S.1200, Senator Dorgan is expected to offer an amendment in the nature of a substitute to replace the text of the version of S.1200 reported out of the Indian Affairs Committee. The substitute will include an updated version of Title I of the bill reported out of the Indian Affairs Committee, as well as the provisions of S.2532 reported out of the Finance Committee (Title II). Note that this Legislative Bulletin describes the highlights of the most recent draft of the Amendment in the Nature of a Substitute to S.1200, though as of the time of publication, the amendment is still subject to further revision.
The DPC will publish additional information on amendments when it becomes available.
As of the time of publication, the Bush Administration has not issued a Statement of Administration Policy regarding this bill.
CRS Report for Congress, “Indian Health Service: Health Care Delivery, Status, Funding, and Legislative Issues” (Updated January 16, 2008), available at http://www.congress.gov/erp/rl/pdf/RL33022.pdf.
 The term “American Indian” as used in this document generally refers to Alaska Natives as well as American Indians.
 The Community Health Representatives Program is a federal program that seeks to address health care needs through the provision of community-oriented primary care services, including traditional Native concepts in multiple’ settings, utilizing community-based, well-trained, medically-guided health care workers. The program was implemented to improve the health knowledge, attitudes and practices of Indian people by promoting, supporting, and assisting the IHS in delivering a total health care program.